Transcript

Norman Swan: Hello and welcome to the Health Report with me, Norman Swan.

At the moment on the program I'm running a series on health reform, and while that sounds a bit dry, it's actually something you need to be acutely aware of if you care about the future of your own and your family's health. Some would argue that Australia is moving away from universal health coverage. Some states are already limiting what they offer in the public sector. Try getting your varicose veins done in Queensland for instance.

We have amongst the highest out-of-pocket costs for health care in the world. Have you, for instance, had surgery in the private sector recently and been shocked at how much you've had to pay yourself despite having had health insurance for years? And that's not even to mention the jungle you have to cut your way through to even pay your bills in the first place.

We have a system based on paying doctors piece rates when what's often needed is a style of holistic, coordinated and consultative care which makes health professionals actually do the jobs they were trained to do to the peak of their capacity and which lends itself more to salaried practice rather than fee for service, which can create incentives to increase inappropriate interventions.

We still have disconnected care in the community and between the community and hospitals.

A couple of weeks ago we heard about the Obama reforms which have elements we can learn from. At least half if not more of US doctors are now salaried and the huge American investment in comparing the effectiveness of treatments could mean higher quality and more cost effective health care.

These are issues that affect everyone, and knowing about them can help to hold our politicians and bureaucrats to account.

This week we're looking at the English NHS, the National Health Service, and as a once upon a time Scot I do mean English, since the British healthcare systems are now separated.

Their reforms start today, that's if you're listening to the Health Report on Monday, and involve general practitioners, GPs, having the budget to buy health services on behalf of their patients, as well as opening up the NHS more to private providers. Some say these are the biggest reforms ever in the history of the British National Health Service since it began in 1948.

Nick Black is Professor of Health Services Research at the London School of Hygiene and Tropical Medicine.

Nick Black: Yes, there are pretty extreme views in both directions. So when the government first announced its reforms, those who believe that market forces should have much greater part felt that this was the opportunity to do that, and therefore those on the left were very concerned and words like 'privatisation of the NHS' were bandied around.

The other extreme, the real marketeers felt that it didn't go far enough. The truth is that both groups are going to be disappointed. My view is and has been from the start, from 2010, is that the NHS is going to look pretty similar this year, 2013, and going forwards, as it did previously, that it's much more about reorganising the existing system rather than introducing any radical change to the system.

Norman Swan: We'll go to what the reform actually is in a moment, but it had general practitioners, the British Medical Association, the Lancet and various other good organs in an uproar and it looks as though the health minister himself, his future was being threatened as well.

Nick Black: That's right. It would be fair to say that the majority of people working or associated with the NHS were opposed to the reforms on the grounds that they saw it as privatisation. In practice we already had…the major change to the NHS since 1948 occurred in 1991 under Margaret Thatcher with the creation of an internal market, by which I mean separating some NHS bodies that would do the commissioning or purchasing of care, representing populations, and some who would provide care; hospitals, general practitioners and so on. And that's the fundamental change in the health service that has occurred since 1948.

Norman Swan: So this is the thing where rather than doling out money to hospitals on an historical basis you said we're going to buy the services and be fairly specific about it.

Nick Black: Yes, and the separation of these two functions, of purchasing and providing, the idea was that by using market forces within a public sector…so this isn't about privatisation, but within a public sector, you would get the benefits that markets produce (it is alleged by those who believe in markets) in terms of improvements in productivity and quality.

Norman Swan: So if I'm going to buy 10,000 hip replacements, we'll have people competing on price, even in the public sector, to provide those hip replacements?

Nick Black: No, not competing on price. It has always been competing on quality. So the providers of, say, a hip replacement will be paid the same in any hospital in the country. That is not negotiable. What they will have to compete on is quality, and that doesn't change. The only thing that changes is that the government is committed to greater diversity of providers, that it shouldn't just be the public sector hospitals that can provide services paid by the public sector but private sector hospitals and ambulatory surgical centres and so on should also be allowed to do it. Now, this actually was nothing new, it was already going on under the previous Labour government, but the coalition government and essentially the Conservative Party wanted to see more use of private providers, and this of course alarmed many of the GPs and hospital doctors in the NHS hospitals.

Norman Swan: But you also have general practitioners with essentially most of the budget for the health system. They're the ones who are buying.

Nick Black: Right, well, the change now is that those who are commissioning, who are purchasing care, we are changing the nature of that commissioning body. Previously primary care trusts were dominated by managers, finance directors and so on, and…

Norman Swan: So what was a primary care trust?

Nick Black: Okay, a primary care trust was the commissioning body for a population, if you like, for a district, perhaps as small as 200,000 population, perhaps as large as almost a million, it varied in different parts of the country. And the primary care trust was a body that was given a fixed budget by the government based on the size of the population, adjusted for age and the usual things, and their job was to purchase secondary care, hospital care.

What has changed is that the primary care trusts, of which there were about 150, have been done away with and they've been replaced by about 210 clinical commissioning groups. What's the difference? Well, the difference is that the clinical commissioning groups are dominated by the GPs, whereas before, the primary care trusts, the GPs simply had a voice at the table, they didn't control it.

Norman Swan: So essentially they were like mini bureaucracies.

Nick Black: Well, they are both still bureaucracies, which is what we want. I think a bureaucracy is a good thing, it's about transparency, it's about avoiding fraud, it's about making absolutely transparent what the decisions are based on. The only difference is that the GPs and to some extent the primary care nurses have more say over how the resources are spent than they did before.

Norman Swan: What difference has it made? You still hear in the United Kingdom of people with unacceptable delays in cancer care. It has taken a long time to get your heart disease mortality down. In Australia and the United States we've been seeing 2% per annum reduction for well over 30 years and it's really only relatively recently that that has happened in the UK. What difference has it made having general practitioners or primary health care trusts buying for populations?

Nick Black: Well, the GPs buying for populations is only about to start, so I can't answer whether the clinical commissioning group's performance will be any better than their predecessors, the primary care trusts. Those who advocate clinical commissioning groups and the role of GPs obviously believe it's going to be much better…

Norman Swan: On the basis of no evidence.

Nick Black: On the basis of no evidence, but because doctors are in more control, somehow this is going to magically make better decisions and better use of resources. Obviously those GPs who are strong advocates of it, who are only a minority, believe it's going to transform things and that the money will be much better spent on the 'correct' things and not be diverted to things of less importance.

Norman Swan: Such as?

Nick Black: I think things like care of people with dementia, care of…

Norman Swan: So more focus on chronic illness?

Nick Black: Yes, and on the sorts of problems they see rather than perhaps some of the more specialised care where we are on the flat of the curve with minimal benefits at quite high costs. But also the pattern of care, of shifting much more care out of hospitals and to the community, getting consultants to act as consultants and not taking over the care of patients, getting the consultants to work much more closely with the GPs both physically by coming out and running specialist clinics outside of the walls of the hospital, but also virtually. And obviously with changing information and communication technology, that becomes easier and easier to do. So I think there are all sorts of transformations that most people agree are desirable and necessary which aren't taking place as rapidly as is needed.

Norman Swan: So the primary care trusts weren't doing that.

Nick Black: The primary care trusts were generally, it's agreed, not a great success at commissioning. It's unfair on some of them who were starting to do some really interesting and innovative things. So you go down to Torbay in Devon, you had the primary care trust more or less merging with the local authority responsible for social services, social care, almost putting their budgets together to provide much more appropriate packages of health and social care for their elderly population. But that was exceptional. The majority of primary care trusts more or less did this year what they did last year and maybe tweaked a little bit at the margins, but you weren't getting the radical changes that are needed in the way we provide healthcare.

Norman Swan: And what about the things that get the headlines and the tabloids, waiting lists for hip operations, infections in hospital, cancer care and survival?

Nick Black: Well, I don't think commissioning will make any difference to any of those things. These are issues that are about quality management within the providers and changes of clinical practice and so on.

Norman Swan: So in other words the jury is out at the moment, come back in a year or two and we'll find out.

Nick Black: Absolutely. We are as interested as you are to know what the answer is.

Norman Swan: And just one final thing before we move on to another major area of research and of great interest I'm sure to our audience, is the criticism of the Thatcher reforms was that…or one of them was the cost of administering it, that the bureaucracy around purchasing was enormous, almost double the cost of managing the health system. Has that been the case more recently?

Nick Black: Well, there is more cost involved if you split purchasing from providing, it is true. How large it is is hard to estimate. On the whole, management costs overall in the English NHS are very low compared with equivalent health care systems in other countries, even with splitting purchasing from providing. It's probably 2% or 3%. The new system, the reforms with the clinical commissioning groups, there is no reason to believe that that will be any more costly or cheaper than the current system.

Norman Swan: Patient reported outcomes. You've been a pioneer in this area. What are we talking about?

Nick Black: What we're talking about, for the moment just with elective surgery, things like hip replacements and hernia repairs, is finding out from patients what benefit they get from surgery. Historically if there were any outcomes measured routinely, it tended to be what the clinician thought. Most of the time we had no idea what the outcomes were, apart from when something went very badly wrong and an operation had to be repeated. But we didn't know the run-of-the-mill operation, how much benefit a patient was getting from a hernia repair, because the reason a hernia repair is done, apart from avoiding any later problems, an emergency which can arise but fairly rarely, is to improve that person's quality of life. So a man can play a round of golf where he couldn't before because of the troublesome hernia, for instance.

Norman Swan: Whereas the surgeon would judge it as; was it infected, did it come back.

Nick Black: Yes, the surgeon, if he saw the patient at all, would have a look at the wound, would see that he'd done a nice job, it had healed nicely, no scar tissue, and the patient said, 'Yes, I'm fine.' What we don't know is a year later was that patient enjoying the quality of life which was the reason that they wanted the operation done in the first place.

So what we've been doing in England since 2009 is for four operations—hip replacement, knee replacement, hernia repair and varicose vein surgery—is to say that all patients in the NHS having one of those operations, which is about a quarter of a million a year, must be invited to fill in a questionnaire before they have surgery reporting on their state of health, their symptoms, the extent to which the problem is affecting their disability, the effect it's having on their quality of life, and then asking them again three or six months later (depending on the type of procedure) how they are now. And by comparing the two we can see the amount of gain in quality of life or in disability reduction.

What are we going to do with that data? Well, what we're doing is comparing the outcomes of different providers, be they NHS public sector providers or private providers doing work for the NHS. And that has now been going for…we are now into the fourth year of that.

Norman Swan: And what proportion of people are agreeing to have this done to them?

Nick Black: The proportion varies a bit by procedure. For hip and knee replacement it's about 80%. For hernia, varicose veins, it's nearer to 60%, 70%, but that doesn't reflect patient refusal. I mean, very few patients refuse indeed, 1% or so. It's largely staff forgetting to invite them, sometimes just because it's not a well-organised clinic, sometimes it's just overwork and it's just too busy to do it.

Norman Swan: So what have you learned?

Nick Black: Well, what we've learned is…I suppose the first and foremost is that these four operations produce enormous benefit for patients, some more than others. Hip replacement transforms people's lives. Secondly, that there is not a lot of variation between providers. We have ways statistically of judging whether a provider is so different from the average as to be concerned about it. What we've found is that none of the providers are actually producing results that are very much worse than average, which is what the NHS was built on, was that there would be satisfactory care provided for everybody, irrespective of where they are living.

Where there are differences is on things like complication rates, where we have found, say, on hip replacement two-fold differences in the complication rates between hospitals. But on the actual amount of benefit from the operation, improvements in quality of life, it's pretty uniform.

Norman Swan: So what do you do with the complication rates? Are you able to find out why?

Nick Black: Well, then it's up locally for that provider to try and understand why they are. There are a number of things they can do. They can look at and compare the complication rates, say, between their six surgeons. We don't do that at a national level, we just report the overall hospital. But clearly within a hospital…it might be to do with the surgeon, it might be to do with the way their post-operative care is organised.

Norman Swan: So is it worth proceeding with it, given that you haven't found any, you're going to move on to another four operations and forget about those four?

Nick Black: It is worth it in terms of two things. One is that one of the intentions is that the outcomes, by providing this and reporting this information to the public, it provides reassurance and secondly it will drive the whole distribution up. In other words, everybody's performance will improve. On things like complications where there are some hospitals where you or I, seeing that data, might decide I won't go there, there's an alternative nearby which has a lower complication rate…

Norman Swan: Do you publish those figures?

Nick Black: Oh yes, those figures are published…

Norman Swan: So you know where the high performing hospitals are.

Nick Black: Oh yes, it's all published completely openly, identifying every provider, public or private.

Norman Swan: And is it changing the marketplace, because in New York State when they did it with coronary artery bypass surgery people knew where the high performing hospitals were but they tended not to go there. It didn't change the market that much, knowing.

Nick Black: It's a slightly different story because, say, in New York State it did have an impact. What it tended to do was to drive out of the market the really low-volume providers, the people doing small numbers of coronary surgery. Of course a system like the NHS, we don't have low volume providers for these common things. So that isn't going to happen.

Nick Black: Again, I'm afraid you're going to have to come back and ask me that in a couple of years because we are just analysing that data now. We've got three years of data, so we're just starting to pick up and look at any trends.

Norman Swan: There is some evidence I thought about patient related outcomes, that people, if they've been waiting a long time for an operation they are almost pathetically grateful, so anything feels good. And it's very rare for people to complain about their care, they are usually very happy with the care that they get, and this seems to be an international phenomenon. Is it related to how long they've waited?

Nick Black: First of all, most of these people at the moment are not waiting very long because there aren't very long waiting times in the English NHS in 2009, '10, '11. It's starting to increase…

Norman Swan: What's the waiting time for a hip replacement?

Nick Black: About three months, which actually for most people is…by the time you've organised your life from having been told you need an operation and agreeing to it, is what most of us would be comfortable with. Of course some of the people are having it within a month, but about 80%, 90% have it within three months. We believe the validity of the data because the questionnaires are sent to patients in their own homes, say, six months later with hip replacement. So they are not under any pressure from surgeons, hospitals, to say anything apart from answer the truth, how far can you walk, how much pain are you getting. There is no danger of any comeback.

I think the other point you raise which is very interesting is does the experience the persons have of the care, by which I mean the way they were treated, the way the doctors and nurses talked to them, whether they got the information they wanted, were they treated with dignity and respect, does that influence how they report the outcomes? So if they actually, looking back, felt that it was a really unpleasant experience, my guess is they might be more inclined to make a lot of a little bit of pain and complain more and report a worse outcome.

Equally, if they have a poor outcome they might be more likely to complain about the experience of the care that they had. Interestingly there is virtually no research in the world looking at the relationship between patient outcomes and patient reported experience. This is some work we're just about to start doing with some data from England where experience and outcome has been collected on hip and knee replacements.

Norman Swan: Nick Black is Professor of Health Services research at the London School of Hygiene and Tropical Medicine. And you're listening to the Health Report here on RN with me, Norman Swan.

Guests

Professor Nick Black

Professor of Health Services ResearchLondon School of Hygiene and Tropical MedicineLondon

Credits

Presenter

Dr Norman Swan

Producer

Brigitte Seega

Comments (5)

David Richards :

01 Apr 2013 10:28:07pm

From my experience having worked as a GP in the UK, NZ & Australia, the NHS offers the worse of all worlds. It's a bureaucratic monolith incapable of adaptation. As a result health care is fossilised in the 20th century. Budget holding was an attempt to galvanise competition and foster ingenuity, but it's a perverse system where GP's are rewarded for not treating their patients, any savings that are made being diverted to 'practice improvements'. A study published in Nature last year showed Australia to be doing extremely well in terms of survival for dollars spent on health care, with only Japan and Switzerland doing better. In fact life expectancy in Australia is one of the highest in the world after Japan, even including outcomes from the Indigenous population. If we're looking for inspiration I'd suggest we look to Japan or Switzerland. By comparison UK life expectancy ( & USA) is almost 5 years less than Australia, despite similar per capita expenditure.

cross :

02 Apr 2013 10:33:25pm

Do you gap by any chance?NHS is the best possible health system in the world, true and free at the point of service and it puts the patient in the centre.I hope you are satisfied by your material gains over here

David Richards :

03 Apr 2013 12:04:36pm

As much as a health system free at the point of delivery sounds wonderful, in reality you have to look at what's actually being delivered. It actually puts government expenditure at the centre of the system, as in any centralised system the patients are at the periphery. You are seriously misguided if you think doctors are significantly advantaged materially in Australia; some are, many are not. It's irrelevant anyway to any discussion of what makes a better system. Hopefully we are all better off, which is what makes this a great country to live in.

Viktoria King :

10 Apr 2013 6:28:04pm

As an Australian clinician who worked in a NHS Primary Care Trust the biggest difference I saw pre 2009 and Australia was accountability. On return I can't see it in the Australian healthcare systems and I believe putting GP's at the centre of care in the NHS means they will no longer be held accountable and (like in Australia currently) the patient misses out.

David Richards :

11 Apr 2013 6:43:01pm

Accountable to who? In the UK once a patient enrols with a GP it is almost impossible to change practice unless you move to another region. Patients are limited to practices in their local areas and choice is almost non-existent. If my patients aren't satisfied with the care I offer, they can obtain another opinion wherever they choose. They are not restricted by Primary Care Trusts or red tape. In fact they can obtain as many opinions as they like, which is unheard of in the UK.

This is accountability, where the patient has the right to choose. I am accountable to my patients, to whom I owe a duty of care and this is as it should be. Thankfully I am not accountable to a Primary Care Trust or Medicare Local, so I can focus on delivering the best quality care to my patients.